Beyond morphology: new coronary physiologic approaches to interventions.
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Blood Flow Velocity↗
Biomedical subjects
G Casella
Publications and source records attributed to G Casella.
Successful treatment of coronary artery perforation during angioplasty using a new membrane-coated stent.
We report a case of successful treatment of coronary artery perforation and cardiac tamponade, which developed during percutaneous transluminal coronary angioplasty, with a PTFE-coated stent. Intravascular ultrasound was first used to overcome the shortcomings of conventional angiography and overlapping of a conventional stent was not as effective as coated-stent placement in sealing a further leakage. Thus, PTFE-coated stents may be an effective alternative to emergency surgery or autologous venous covered stenting and should be considered when coronary artery perforation occurs.
Aged↗
Antithrombin III (ATIII) replacement therapy in patients with sepsis and/or postsurgical complications: a controlled double-blind, randomized, multicenter study.
BACKGROUND: ATIII is decreased in sepsis and/or shock and its baseline value correlates with mortality. The efficacy of ATIII therapy on mortality was assessed in a selected group of patients admitted to the intensive care unit (ICU) in a double-blind, randomized, multicenter study. METHODS: 120 patients admitted to the ICU with an ATIII concentration < 70% were randomized to receive ATIII (total dose 24000 units) or placebo treatment for 5 days; 56 patients had septic shock. RESULTS: ATIII concentrations in the treated group remained constant throughout the treatment period (range 97-102%). The Kaplan-Meier analysis showed no difference in overall survival between the two groups: 50 and 46% for ATIII and placebo, respectively. Septic shock and hemodynamic support were unbalanced in the two groups at admission. Therefore the Cox analysis was carried out after adjusting for these two variables. Treatment with ATIII decreases the risk of death with an odds ratio (OR) of 0.56. Of the covariates analyzed, septic shock and the baseline multiple organ failure score were negatively associated with survival and plasma activity level was positively associated with survival with an OR of 0.97 for each 1% increase in the ATIII plasma concentration at baseline. CONCLUSIONS: The results of ATIII treatment in this population of patients suggests that replacement therapy reduces mortality in the subgroup of septic shock patients only.
APACHE↗
Long-term prognosis of painless exercise-induced ischemia in stable patients with previous myocardial infarction.
OBJECTIVES: This study was designed to better understand the functional correlates and the prognostic relevance of exercise-induced painless ischemia relative to painful ischemia in patients with stable coronary artery disease and previous myocardial infarction (MI). BACKGROUND: The usefulness of exercise testing (ET) for predicting cardiac events, years after MI, although suggested and widely applied, is questionable. In particular, previous studies have reached conflicting conclusions as to whether exercise-induced painless ischemia is related to a less severe myocardial ischemia or to a different prognosis than painful ischemia. METHODS AND RESULTS: Seven hundred sixty-six consecutive stable patients (mean age 57+/-8.6 years, 89% men) with previous MI (mean time from MI 2.8+/-0.75 years) who underwent a Bruce treadmill test and whose data were prospectively entered into our institutional database were enrolled. Patients were followed up for an average of 7+/-0.6 years. End points were (1) cardiac death, (2) cardiac death or nonfatal reinfarction (primary), (3) cardiac death, nonfatal reinfarction, or unstable angina (secondary), and (4) cardiac death, nonfatal reinfarction, unstable angina, or revascularization procedures (secondary, restricted). These patients were retrospectively classified into 4 groups according to exercise test results: (1) painless ischemia, 156 patients; (2) painful ischemia, 75 patients; (3) negative ET, 99 patients; and (4) nondiagnostic ET, the remaining 436 patients. Patients with painless ischemia had less functional impairment and less exercise ischemia than the symptomatic patients (longer exercise duration [P < .001], higher double product [P < .001], higher ischemic threshold [P < .001], and shorter time to ST normalization [P < .001]). Patients with painful ischemia had significantly (P < .0005) increased 6-year risk rates of secondary and restricted end points (49% and 64%, respectively) versus those with painless ischemia (28% and 35%), no inducible ischemia (25% and 27%), or nondiagnostic ET (32% and 37%). Adverse outcomes were mainly the result of higher incidence of unstable angina or revascularization procedures. At multivariate analysis, neither painless nor painful exercise-induced ischemia were independent predictors of end points. CONCLUSIONS: Stable patients with previous MI represent a very low-risk population. In this subset, painless exercise-induced ischemia signifies less severe ischemia than the symptomatic one and has a limited prognostic power. Thus painless exercise-induced ischemia in stable patients with previous MI does not identify patients at increased risk.
Adult↗
Can exercise testing in patients with a history of myocardial infarction predict fatal and non-fatal reinfarction?
BACKGROUND AND OBJECTIVES: Exercise testing (ET) is the preferred initial strategy for risk stratification in patients who are able to exercise and have an interpretable electrocardiogram. However, although it is often suggested and widely applied, its usefulness years after myocardial infarction (MI) is questionable. Therefore, this study was designed to assess the value of exercise testing in predicting the risk of fatal or non-fatal reinfarction in patients with chronic stable coronary artery disease (CAD) due to old myocardial infarction. METHODS: Our study involved 766 consecutive stable subjects [mean (SD) age 57 (8.6) years; male: 89%] with stable CAD due to old MI [mean time from MI: 2.8 (0.75) years], who underwent a Bruce treadmill test and whose data were prospectively entered into our institutional database. Patients were followed up for an average of 7 (0.6) years. RESULTS: Reinfarction was observed in 62 patients; 54 non-fatal and 8 (13%) fatal. Relative risk (RR) of cardiac death for subjects with reinfarction was 4.02 [95% confidence interval (CI): 2.46 to 6.55]. Univariate predictors of fatal or non-fatal reinfarction were: multivessel disease (RR 7.99, CI 1.12 to 56.82), EF < 40% (RR 2.91, CI 1.64 to 7.17), ST depression on rest ECG (RR 2.4, CI 1.30 to 4.45), BP increase with exercise < 10 mmHg (RR 2.36, CI 1.41 to 3.93), BP/HR interaction < 10 mmHg + < 85% max (RR 2.16, CI 1.24 to 3.76). Markers of reduced risk of recurrence included low-risk Duke Treadmill Score (RR 0.55, CI 0.33 to 0.91) and EF > or = 40% (RR 0.34, CI 0.19 to 0.60). A Cox regression model with clinical and exercise parameters detected ST depression on rest ECG (RR 1.47, CI 1.07 to 2.02), BP increase with exercise < 10 mmHg (RR 1.41, CI 1.07 to 1.87), low-risk Duke Treadmill Score (RR 0.79, CI 0.60 to 1.02). A model with coronary anatomy and ejection fraction was also able to identify multivessel disease (RR 2.95, CI 1.43 to 6.09), EF < 40% (RR 1.62, CI 1.17 to 2.25) and BP increase with exercise < 10 mmHg (RR 2.53, CI 1.35 to 4.71). CONCLUSIONS: Stable patients with a history of MI represent a very low-risk population in whom reinfarction continues to have a severe prognosis. ET is unable to identify subjects in whom there is a risk of recurrence, especially if only ischemic parameters are evaluated (in this setting, a clinical or anatomic risk stratification may be better). The application of the Duke Treadmill Score could help to identify a very low-risk group in which no additional testing is required. Therefore, routine ET in stable patients with a history of MI is better at identifying a very low-risk group than in predicting recurrence.
Adult↗
Primary malignant melanoma of the vagina: case report.
Primary vaginal melanoma is a very rare gynecological malignant tumor (less than 150 reported cases to-date). Prognosis is poor in spite of treatment. Due to the fact that only small groups of patients have been compared, conservative treatment has usually been recommended. In recent times, radical pelvic surgery has appeared to improve the chances of survival. We present an unusual case of primitive melanoma of the upper-third of the vagina with urethral and urinary bladder infiltration in a 47-year-old woman. Treatment consisted of preliminary pelvic bilateral lymphadenectomy, anterior exenteration, and urinary bladder reconstruction according to the Bricker technique. Four months after surgical treatment, liver metastases were found. Chemotherapy was initiated consisting of 8 cycles every 21 days of fotemustine 100 mg/m2 (day 1) and dacarbazine (DTIC) 250 mg/m2 (days 2-5). Interferon alpha-2-b, 3 MU thrice weekly, for the whole period of chemotherapy, was also administered. The patient is in partial remission one year after surgical treatment.
Antineoplastic Combined Chemotherapy Protocols↗
Surgical treatment of invasive carcinoma of the vulva: two different techniques.
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Carcinoma, Squamous Cell↗
Conization of the uterine cervix: two different surgical techniques.
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Adult↗
An open multicentric study evaluating 4-hydroxybutyric acid sodium salt in the medium-term treatment of 179 alcohol dependent subjects. GHB Study Group.
We report the results of an "open' multicentre study evaluating the use, tolerability and therapeutic efficacy of the sodium salt of 4-hydroxybutyric acid (GHB) for the medium-term treatment of withdrawal symptoms in 179 patients with alcohol dependence followed up as outpatients. The follow-up of patients was 6 and 12 months after drug discontinuation. Following a daily oral administration of 50 mg/kg for approximately 6 months, no serious systemic or single-organ consequences leading to drug discontinuation were reported, and tolerability was fair in all patients. Eleven subjects (10.1%) showed craving for the drug and voluntarily increased their doses (6-7 times the recommended levels). GHB led to complete abstinence during drug administration in 78.0% of the patients. A significant reduction of compulsive desire ("craving') was observed in parallel, as deduced from evaluation of a specific questionnaire, the Alcohol Craving Scale. At follow-up examination, 43 of the treated subjects remained abstinent at 6 months, and 30 subjects were abstinent for 1 year after drug discontinuation.
Adolescent↗
Event-time analysis of the effect of 60-day milk production on the parturition-to-conception interval in dairy cows.
OBJECTIVE: To quantify the effect of early-lactation milk and milk fat production on time to conception. DESIGN: Event-time analysis (survival analysis). SAMPLE POPULATION: 44,450 cows delivering calves between September 1985 and September 1986, from 6,227 Ayrshire dairy herds in 80 Finnish communities. PROCEDURE: Primiparous and multiparous cows were analyzed in separate Cox proportional hazards models. 60-day milk and milk fat production were categorized and regressed against days from parturition to conception for the period 56 to 120 postpartum days, controlling for season of parturition, parity, herd production, occurrence of 43 diseases, and community. RESULTS: Multiparous cows producing above the 80th percentile for 60-day milk, but with milk fat production below the 75th percentile, were significantly more likely to conceive, compared with cows with lower production and compared with cows with similar milk production but with milk fat between the 75th and 97th percentiles. They were slightly more likely to conceive than cows with highest milk fat production, although not significantly so. Primiparous cows producing above the 80th percentile for 60-day milk with milk fat below the 75th percentile also had the highest conception probability. The highest producing primiparae had significantly lower conception probability than all others. CONCLUSIONS: Controlling for disease occurrence, calving season, parity, herd production level, and community, there appeared to be an inverted U-shaped relation between 60-day production and conception probability. CLINICAL RELEVANCE: Primiparous cows that are high producers may not be receiving the same careful management that high-producing multiparous cows receive.
Aging↗
Event-time analysis of the effect of season of parturition, parity, and concurrent disease on parturition-to-conception interval in dairy cows.
OBJECTIVE: To quantify the effect of season of parturition, parity, and various diseases on time to conception. DESIGN: Event-time analysis (survival analysis). SAMPLE POPULATION: 44,450 cows delivering calves between September 1985 and September 1986, from 6,227 Ayrshire dairy herds in 80 Finnish communities. PROCEDURES: Primiparous and multiparous cows were analyzed in separate Cox proportional hazards models for postpartum days 56 to 120. Occurrence of 43 diseases or disorders was recorded; codes were condensed into 25 variables offered to each model. Season of parturition was categorized into spring, summer, and fall-winter; for multiparous cows, 3 categorical variables represented parity. Models controlled for 60-day milk and milk fat production, herd milk production, and community. For all observations, parturition-to-conception interval was plotted against calendar day of parturition. RESULTS: For multiparous cows, parturition in the spring or summer and being of parity 2 or 3-4 (vs older) increased the chance of conceiving; 10 diseases or disorders decreased this probability. Similarly, in the model for primiparae, parturition in spring or summer increased the probability of conception, and 6 disorders decreased it. Disorders that were detrimental in both models were anestrus, ovulatory dysfunction, other infertility, late metritis, and clinical ketosis. CONCLUSIONS: The effect of season on the parturition-to-conception interval was marked at this latitude. Parturition during late April, causing confluence of postpartum day 55 with the summer solstice, was associated with the shortest parturition-to-conception intervals. Ketosis was found to be an important factor in lengthening the parturition-to-conception interval, highlighting the effect of negative energy balance on postpartum restoration of reproductive function.
Animals↗
[ST segment depression during recovery after treadmill exercise test in stable patients with previous myocardial infarction].
BACKGROUND: The significance of exercise-induced ST segment depression is well known while limited data are available on the clinical/prognostic power of ST depression occurring only during recovery. Aim of the study was to clarify the clinical/prognostic value of "recovery only" ST depression in stable patients late from myocardial infarction (AMI) and to determine whether the addition of recovery data to exercise parameters improves the interpretation of exercise test. METHODS: From a population of 766 consecutive patients (mean age: 57.2 +/- 8.6 yrs.; male: 89%) who underwent a Bruce Treadmill test at least 1 year after a Q wave AMI and whose exercise data were prospectively entered in the database of our Institution, 4 different Groups were identified: 1) 99 patients with a negative exercise test; 2) 53 patients with "exercise only" ST depression; 3) 140 patients with "exercise and recovery" ST depression; 4) 31 patients with "recovery only" ST depression. The main clinical and exercise data and a cardiac follow-up (average mean length: 1530 +/- 600 day) were evaluated by one-way analysis of variance, Bonferroni T-test, chi-square, relative risk (RR) with 95% confidence intervals (CI), Kaplan-Meler method and log-rank. RESULTS: Baseline clinical parameters were similar in the 4 Groups except for older age in Group 3 compared to Group 2 (< 0.05) and higher prevalence of anterior AMI in Group 4 compared to others (= 0.004). Patients with exercise and recovery ST depression or with "recovery only" ST depression had significantly less exercise tolerance than patients with negative exercise test or "exercise only" ST depression [exercise duration (< 0.05, Group 1 vs. 3, vs. 4; Group 2 vs. 3), peak rate pressure product (< 0.05), maximal heart rate (< 0.05; Group 1 vs. 2; vs. 3; vs. 4)]. Exercise-induced ST depression was higher and angina was significantly more frequent in patients with exercise and recovery ST depression as well as an high Mark's risk score (< 0.001). Only patients with exercise and recovery ST depression demonstrated significantly higher risk of overall mortality (RR: 1.35, CI: 1.04-1.74), unstable angina (RR: 1.34, CI: 1.09-1.65) or revascularisation procedures (RR: 1.51, CI: 1.25-1.83). Relative risk of patients with "recovery only" ST depression was similar to that of subjects with "exercise only" ST depression. CONCLUSIONS: In stable patients with old Q wave AMI, "recovery only" ST depression is rate, but does represent a true sign of ischemia. It could be associated with indirect indexes of worse ventricular function. The prognostical power of "recovery only" ST depression is mild, although similar to that of "exercise only" ST depression. Moreover the presence of ST depression not only during exercise but also during the recovery phase identifies patients with more severe prognosis. Therefore the inclusion of findings from the recovery phase in the analysis of the exercise test could increase the predictive power of the test itself.
Aged↗
CEDIA for screening drugs of abuse in urine and the effect of adulterants.
The performance of the Microgenics CEDIA DAU assays for screening amphetamines, barbiturates, benzodiazepines, cocaine, opiates, phencylidine (PCP), and tetrahydrocannabinol (THC) was evaluated on the Boehringer Mannheim/Hitachi 717 in urine. Limits of detection ranged from 0.6 ng/mL for PCP, to 34.1 ng/mL for benzodiazepines. The average within run and total precision for these assays ranged from 1.3 to 7.3% for controls at cutoff concentrations, and control values at -25% and +25% of cutoffs. The rate separations by CEDIA between the negative and cutoff calibrators for all drugs were greater than corresponding EMIT II (Syva Co.) assays. The relative sensitivity and specificity of CEDIA as compared to EMIT II were 95.6 and 98.8%, respectively, on 13,535 urine samples. All positive samples, and those samples producing discordant results between the assays were confirmed by quantitative gas chromatography/mass spectrometry (GC/MS). Using SAMHSA cutoff limits (and including barbiturates and benzodiazepines at 300 ng/mL), the relative sensitivity and specificity of CEDIA vs. EMIT II were 96.7 and 98.8%, respectively. The overall sensitivity of CEDIA vs. GC/MS was 98.9% with 179 false positives, as compared to 96.2% with 189 false positives for EMIT II vs. GC/MS. The effect of adulterants added to urine to potentially invalidate screening results was also tested. CEDIA produced strong interferences for most drug assays in the presence of glutaraldehyde, detergent, and high concentrations of bleach and Drano. Minimal or selective interferences were seen with golden seal tea lemon juice, Visine, and low concentrations of bleach and Drano. Essentially no interference was observed with bicarbonate, sodium chloride, and vinegar.
Gas Chromatography-Mass Spectrometry↗
Prevention and treatment of complications after endoscopic prostheses placement in tumors of the upper gastrointestinal tract.
Endoscopic intubation is a popular palliative method to resolve immediately malignant dysphagia. However, the complication rate is still high. Between 1978 and 1993, at the Division of Diagnostic and Surgical Endoscopy of Istituto Nazionale Tumori in Milan, 305 patients suffering from malignant dysphagia, were endoscopically treated by insertion of an endoprosthesis. We report the analysis of data regarding our complication rate, compared with the literature, and our experience in preventing managing complications related to this endoscopic procedure.
Adult↗
Efficacy of long-term administration of transdermal nitroglycerin in asymptomatic patients with effort-induced silent myocardial ischemia.
The aim of our study was to investigate the effect of transdermal nitroglycerin (NTG) on effort-induced silent myocardial ischemia in asymptomatic patients treated with beta-blockers or calcium antagonists. The acute effect was compared to two different schedules, continuous (24 h/day) or intermittent (16 h/day), of long-term administration. Ten asymptomatic patients with coronary artery disease and a treadmill test positive for ischemia without angina were enrolled. Both acute (2 days) and long-term (24 days) evaluations were conducted in a randomized, double-blind, crossover fashion. The ergometric parameters were collected on the 1st and the 2nd day of the acute phase (placebo and transdermal NTG, respectively) and at the end of each 12-day period of long-term administration (continuous and intermittent, respectively). Transdermal NTG administration acutely increased (p < 0.05) both time to 1-mm ST segment depression (451 +/- 43.2 vs. 374 +/- 24.1 s) and total exercise time (561.3 +/- 43.2 vs. 419.5 +/- 24.5 s). The acute efficacy was maintained over long-term treatment, regardless of the modality of administration. During continuous and intermittent patch application, time to 1-mm ST segment depression was 437.9 +/- 30.4 and 422 +/- 33.4 s (p = NS vs. acute) and total exercise time was 498.8 +/- 30.4 and 495.1 +/- 33 s (p = NS vs. acute), respectively. Transdermal NTG increases, both acutely and chronically, exercise tolerance in asymptomatic patients with effort-induced silent myocardial ischemia. With the NTG dose we used, tolerance does not seem to be a problem over long-term administration.
Administration, Cutaneous↗
Comparative hemodynamic effects of intravenous digoxin and enoximone in severe chronic heart failure.
In order to compare the acute hemodynamic effects of digoxin (0.01 mg/kg) and enoximone (1 mg/kg), a phosphodiesterase inhibitor inotropic agent, in severe chronic congestive heart failure, 8 patients (male, mean age 56.7 years, sinus rhythm) were investigated with a randomized cross-over study. Peak effect of enoximone (30 min) in comparison to that of digoxin (90 min) resulted in a similar reduction of left-ventricular filling pressure (-27 vs. -28%) and mean pulmonary artery pressure (-23 vs. -24%). Pulmonary (-39 vs. -16%; p < 0.01) and systemic vascular resistance (-27 vs. -4%; p < 0.001) were significantly lowered by enoximone. Cardiac index (+30 vs. +6%; p < 0.001) and heart rate (+11 vs. -3%; p < 0.05) were increased significantly more by enoximone than by digoxin. Since enoximone resulted in an enhancement of cardiac performance greater than that produced by digoxin, enoximone could be a useful and powerful substitute for digoxin in the acute therapy of severe chronic congestive heart failure with sinus rhythm.
Adult↗
[Preanesthesia in elderly patients undergoing subarachnoid anesthesia: chlordesmethyldiazepam versus diazepam].
Forty patients over 65 undergoing subarachnoid anesthesia with bupivacaine 0.50% (5 mg) and fentanyl (0.1 mg) were subdivided into two equal groups: one was premedicated with atropine and chlordesmethyldiazepam (0.03 mg/kg-1) and the other with atropine and diazepam (0.015 mg/Kg-1). A statistically significant difference was found in the group treated with diazepam which required an increase for anesthetic drugs during surgery. The authors suggest a probable synergic or an enhanced effect between intramuscular chlordesmethyldiazepam and opiates in spinal anesthesia.
Aged↗
Endoscopic treatment of polyps in the resected stomach.
Between 1974 and 1992, at the Department of Diagnostic and Surgical Endoscopy of Istituto Nazionale Tumori, in Milan, 27 patients with resected stomach and suffering from epithelial polyps of the gastric stump (10 lesions) and/or anastomosis (25 lesions), were endoscopically treated using electroresection (13 cases), electrocoagulation (2 cases), combined methods (electroresection plus Nd:YAG photocoagulation) (1 case) and biopsy forceps (19 cases). Complications occurred in 4 cases and consisted of hemorrhage. Seven patients developed 15 recurrences. Endoscopic treatment of polyps in patients with resected stomach is a safe and effective treatment, considering the low rate of complication.
Adult↗